Addressing the Opioid Crisis in Small and Rural Communities in Western Massachusetts Robert Bohler, MPH, PhD Student, Institute for Behavioral Health, The Heller School for Social Policy and Management, Brandeis University Michael Doonan, PhD, Associate Professor, Schneider Institutes for Health Policy, The Heller School for Social Policy and Management, Brandeis University Constance Horgan, Sc.D., Professor and Director, Institute for Behavioral Health, Schneider Institutes for Health Policy, The Heller School for Social Policy and Management, Brandeis University Friday, September 6, 2019 8:00 a.m. – 12:15 p.m. UMass Campus Center Auditorium 1 Campus Center Way, Amherst MA Copyright © 2019. The Massachusetts Health Policy Forum. All rights reserved. NO. 49 This issue brief is supported in part by the Blue Cross Blue Shield of Massachusetts Foundation, the University of Massachusetts Amherst School of Public Health and Health Sciences, RIZE Massachusetts Foundation, and Baystate Health. The issue brief is being produced in collaboration with the Brandeis-Harvard NIDA Center to Improve System 1 Performance of Substance Use Disorder Treatment and the Opioid Policy Research Collaborative (OPRC). Table of Contents Acknowledgments……………………………………………………………………………………………………………………….3 Executive Summary……………………………………………………………………………………………………………………..4 Introduction………………………………………………………………………………………………………………………………..9 I. The Problem – Underlying Epidemiology ................................................................................... 9 Opioid-related Overdose Deaths .............................................................................................. 10 Opioid Use Disorder ................................................................................................................. 12 Opioid Prescribing .................................................................................................................... 13 Emergence of Fentanyl ............................................................................................................ 14 Who is at Greatest Risk? ………….................................................................................................16 II. The Problem – Cost and Consequences .................................................................................. 17 Economic Impact ..................................................................................................................... 17 Impact on Employers ............................................................................................................... 18 Neonatal Abstinence Syndrome ............................................................................................... 19 Foster Care and Grandparents Raising Children ...................................................................... 19 Criminal Justice System ............................................................................................................ 20 III. Unique Challenges in Western Massachusetts ......................................................................... 20 Transportation ......................................................................................................................... 21 Socioeconomic Distress ............................................................................................................ 21 Access to Treatment ................................................................................................................ 22 Rural Isolation .......................................................................................................................... 23 Trauma…………………………………………………………………………………………………………………………………23 Housing…………………………………………………………………………………………………………………………………23 Data Challenges…………………………………………………………………………………………………………….........24 Stigma ...................................................................................................................................... 24 IV. Community Action and Best Practices ...................................................................................... 25 Community Collaboration ........................................................................................................ 25 Prevention ............................................................................................................................... 27 Early Intervention .................................................................................................................... 28 Treatment ................................................................................................................................ 30 Recovery .................................................................................................................................. 32 Harm Reduction ...................................................................................................................... 33 V. Policy Recommendations ......................................................................................................... 35 Conclusion ................................................................................................................................................................................ 38 Appendix A: Interviewees ................................................................................................................................................. 39 References ................................................................................................................................................................................ 40 2 Acknowledgements We would like to acknowledge the many people in Western Massachusetts who are on the ground fighting the opioid crisis every day and generously agreed to be interviewed (listed in Appendix A). The team was truly inspired by the commitment, passion, and eagerness that was conveyed through the interview process. We would like to extend a special thanks to Debra McLaughlin, Risa Silverman, Dr. Peter Friedmann, Ruth Jacobson-Hardy, Jennifer Kimball, Cherry Sullivan, Wendy Penner, Heather Bialecki-Canning, and Alison Proctor, who functioned as points of contact for other stakeholders, provided guidance in the initial outline of the issue brief, and served as a sounding board in the early development of the project. Thank you to Dr. Elizabeth Evans and Dr. Peter Friedmann for their expertise on the research panel and to the participants of the stakeholder panel, Dr. Ruth Potee, District Attorney Andrea Harrington, Liz Whynott, Debra McLaughlin, and Deidre Calvert, for their insight into the opioid crisis in Western Massachusetts, as well as Dr. Salomon-Fernandez for serving as a moderator for both panels. We thank the many people that comprehensively reviewed the issue brief and provided thoughtful feedback, including Debra McLaughlin, Cherry Sullivan, Ruth Jacobson-Hardy, Linda Jablonski, Julie Burns, Dr. Elizabeth Evans, Dr. Andrew Kolodny, Dr. Peter Kreiner, Dr. Mary Brolin, Dr. Sharon Reif, Dr. Cindy Thomas and Hilary Richards. A special thanks to Lee Panas for his assistance on data analysis and to Ashley Osorio for her invaluable assistance managing this project. We would like to acknowledge James Hiatt and James Hunt of the Massachusetts League of Community Health Centers for their guidance and to the Massachusetts Department of Public Health for their review of the issue brief and the use of their data. Lastly, we would like to thank the leadership and financial support of the Blue Cross Blue Shield of Massachusetts Foundation, RIZE Foundation, UMass Amherst School of Public Health & Health Sciences, and Baystate Health. The Opioid Policy Research Collaborative at Brandeis University, and the Brandeis-Harvard NIDA Center to Improve System Performance of Substance Use Disorder provided other support. 3 EXECUTIVE SUMMARY The opioid crisis is having a devastating impact on public health in the Commonwealth of Massachusetts with specific challenges in rural and small communities in Western Massachusetts. A detailed literature review and 24 stakeholder interviews helped identify those challenges as well as describe action steps being taken in the region and highlight recommendations for future success. Several themes emerged including: the vitality of collaboration and the role of community coalitions in ensuring an effective response, the rehabilitative role of the criminal justice system, innovative solutions aimed to engage more people on medications for opioid use disorder (MOUD), and the necessities of harm reduction strategies and recovery support services (RSS). Beyond the economic toll, the intergenerational impact of this opioid addiction epidemic has left infants born dependent on opioids, grandparents raising grandchildren, an increase of children in the foster care system, and an increasing incarcerated population struggling with opioid use disorder (OUD). While much is being done, the crisis continues. Appropriate access to treatment and supportive recovery in the region is hindered by challenges including socioeconomic distress, inadequate treatment infrastructure and housing, rural isolation, stigma, transportation, and trauma. What was made clear is the degree of community willingness, leadership, innovation, and compassion that the people of Western Massachusetts exemplify, from regional collaborations, to the criminal justice system, to healthcare providers and hospital systems, to harm reduction specialists. The Problem The most recent